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1 OAK ST - BUILDING INSPECTION (2) One or Two-Family Dwelling The Commonwealth of Massachusetts Board of Building Regulations and Standards (� Massachusetts State Building Code, 780 CMR, 7h Edition Application to construct alter, renovate,repair or demolish " ThisSection For Offiarala9se Only Building Permit Number: Date of application: 3 �� Signature: ����� Building Commissioner Local Inspector Date SECTION 1 ;'SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers 1.1a Is this an accepted street? Yes )5, No ❑ Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(0) 1.5 Building Setbacks(feet) Front Yard Side Yard Rear Yard Required Provided Required Provided Required Provided- 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: Outside Flood Zone? Check if yes ❑ Municipal❑ On site disposal system ❑ 1.9 ZBA Special Permit 1.10 Old & Historic Commission 1.11 Conservation Commission Date filed N/A ❑ Date filed N/A ❑ Number 40, N/A ❑ SECTfON 2 PROPERT Y 2.1 Owner BI✓& a A-k ST �OlUF1�l� /s-(l9 �S �R-�Pm Na nt) Address for Service Sign tore of Owner Telephone SECTION 3 I)ESCRU'I ION OF PROPOSED WORK(cheek all that aQply) { New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) Alteration(s) ❑ Addition ❑ Demolition ❑ AccessoryBldg. O Number of Units '—,?—I Other ❑ Specify: Description of Proposed Work: 1A AC SECTION 4.' 'ESTIMATED CONSTRUCTION COSTS BUILDING NEItM'IT FEE ' Estimated Costs labor and mater'als Item ) This Section F��.,x � or Official Use Only 1. Building $ 7dlam. Building: $10/$1000 2. Electrical $ Building+Plumbing: $12/$1000 Building+Electrical: $13/$1000 3.Plumbing $ Building+Electrical+Plumbing combined:$15/$1000 __ 4. Mechanical (HVAC) $ Total project cost(labor and materials)$ S.Fire Suppression $ Fee multiplier from above$ /$1000 6.Total Project Cost $ Cf(Ja, 4J Permit Fee$ Receipt Number /19W/ Td z( /3�9GGey-qs 5T, SECTION,S: ,:C?T STRIJCTI0N,SFRVI6ES 5.1 Construction Supervisor License(CSL) % AWZ Z. yEX t/A�7.W/VA0 r/ License Expiration Date / /3 Name of CSL Type Description 27 Ihm-eJuAl �iv�1T/�Dro r(�i MA. 02/,y U Unrestricted(up to 35,000 Cu.Ft. Addres}I � R M Restricted 1&2 Family Dwelling /L/✓l7,.c M Masonry Only Sig ature RC Residential Roofing Covering 6/j- 6FS�-6�'2d� WS Residential Window and Siding Telephone SF Residential Solid Fuel Burning Appliance D Residential Demolition 5.2 Home Improvement Contractor Registration (HIC) )Pque- L, A&ZVq f YJ9N/AA1 Registration 141020'1 Expiration Date 7/74/) HIC Company Name or HIC Registrant Name 27 Al460cliV AVG- /7)GfAFo6Z1) /hA- 01ts3 Addres�� �u� Sigtrature Telephone �S'EC'tTI�N 6 'WORK$R'S+C�RZPENSt1TION INSURe�N�.`E AFb`hDA�VfT��L,ic"152 §Y2$C(6))�'��+�'� r+ Worker's Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide an insurance affidavit may result in the denial of a building permit. Signed affidavit attached? Yes'x No ❑ S�CTION`7a �OONT�CT'ORfA��IESOO�RBUI�D�ILsT�fGYERN'�YT���QWNERj53���NT�O� p��y- "�`" as Owner of the subject property,hereby authorize Aug 1 ./�c tZV fJRT371U/ A/ to act on my behalf in all matters relevant to work authori by this b 7 ' g ation. 1 Sign re o Owner Date I ,>SECT'ION 7Is r i OWNER AOR AUTHORIZED.AGENT,DECLARAT'IO�1 ,3 � ; r �p� s"r�`f F I, 4JZ D61V14Q]1!N/A/1/ as Owner or Authorized Agent, hereby declare that the V n information on the foregoing application are true and accurate,to the best of my knowledge and belief. SI'gnature of Owner or Authorized Agent (Signed under the pains and penalties of perjury) i. NOTES An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor(not registered in the Home Improvement Contractor(HIC)Program)will not have access to the arbitration program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 1 I0.R5. When substantial work is planned, provide the following information: Total floors area(Sq.Ft.) (including garage, finished basement/attics,decks or porch) Gross living area(Sq.Ft.) Number enclosed of decks/porches Habitable room count Number open of decks/poches Number of bedrooms Number of fireplaces Number of bathrooms Type of heating system Number of half/baths Type of cooling system ACZ?RD CERTIFICATE OF LIABILITY INSURANCE °"TE'MM°°"""' —A. 04/20/2011 PRODUCER (978) 927-8420 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE lrauianzano Insurance Agency HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 107 Dodge Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Beverly MA 01915- INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA:Penn America Insurance CO Rodrigo Guimaraes INSURER B: Guimaraes Construction INSURER C: 21 Balcomb Street INSURER D: Salem MA 01970- INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS', EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATON LTR INSRD TYPE OF INSURANCE POLICY NUMBER DATE(MWDD DATE MM/DD/YY LIMITS A GENERAL LIABILITY PAC6905437 03/09/2011 03/09/2012 EACH OCCURRENCE $ 11000,000 X COMMERCIAL GENERAL LIABILITY. PREMISES TO RENTED occu once $ 100,000 CLAIMS MADE Fx-1 OCCUR / / ` / / MED EXP(Any oneperson) $ 51000 PERSONAL&ADV INJURY $ 11000.000 GENERAL AGGREGATE $ 2,000,000 GEN'1.AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ 2,000,000 X POLICY JECOT LOC AUTOMOBILE LIABILITY / / / / COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO ALLOWNEDAUTOS / / / / BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS •I / / / / BODILY INJURY _ (Per accident) $ , NON-OWNED AUTOS PROPERTY DAMAGE r $ (Per accident; GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO „ / / / / OTHER THAN EA ACC $ AUTO ONLY: AGO $ EXCESS/UMBRELLA LIABILITY / / / / EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE / / / / $ RETENTION $ $ WORKERS COMPENSATION AND / / / / TORY LIMITS a OER EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $ ANY PROPRIETOR/PARTNEREXECUTIVE OFFICER/MEMBER EXCLUDED? / / / / E.L.DISEASE-EA EMPLOYEE[$ If yes,describe under _ SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT I$ OTHER DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLES/EXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION (781) 631-2220 (781) 631-2617 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL _ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT Town of Marblehead FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE Building inspection b*t. INSURER ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE -� Marblehead ad MA 01945_ A{�C, ORD 25(2001/08) ©ACORD CORPORATION 1988 L'6.nw INS025(0108)C5 ELECTRONIC LASER FORMS,INC.-(800)327-0545 Page 1 of 2 CITY OF SALEM it PUBLIC PROPRERTY S . DEPARTMENT .nu'.:su r:oslx. It 1 j^� WASHING It^518CL•1'f S.%I I.te, M.1]1.x.111 xI Iv JI'17: 1'Ho 778.713-9395 o P Lr )7v.7#C••+Y4fi Workers' Compensatlon lnsurunee :%111412vit: lluilders/Contractors/Electrlclans/Plumbers t t )locant Infurination PIr.� Print Le •hl Nome 1-IhnuwviArganlrJliarvinJrouluall: ('rr'1 yl/L Ae S a C •T u C"f- I a (� Address: 2 RA L tiC O PN R Ste- G ( p [/ cily,stme'Zip. S�LV /V-, Thune i1: MA- l 0 6 ! T — Ao 6 2-r- .tro p ou an vngiloyer:'Check the approprlisle Is ; IL 0 1 :un a empluycr with 4. � I :un a general contractor and 1 l yM of pro/Yee(rvvlulred); cliipluyces(full Jnd/ur part-time).• Nave hired the suh•cunlractars (I' 0 new construction ?.0 1 ant a solo prnprictor or partner- lislcd on the anaehcd sheet. t y 0 Remodeling ship amt have no mnpluyecs Theca sub-contractors have Y. 0 Demolition working torr me in any capacity, workers'comp. insurance. I Nn workers'cutup. insurance S. 0 Weare a colporetion and its 9. 0 ouikling addition required.) )tytccrs have cacciscd their 10.0 Electrical repairs or additions 1.0 1 ant a hnmcuwncr doing all work right of caemption par b( IL 11. myself.Igo workers,comp. e. 152,§I(4),and we have no 0 Plumbing re puiro or aJJitiorts nsurance required.) r employees. lNo wofkM' 12.0 Rtwl'npairs conf% ilhuranLv - uind. 1J•OOther til .,, q 1 rkcua Flits f .l I W check � dada ImuM:J W IIIIng JW it@ lml g At ItIrt find IhVlr,Wwkln ad111ellllyd(ym IMr11ey IIIfIrr11W1jyr\ 'Ilulnmh"A wtlo rlarinir bell amu j it ilhod.lina theydItk Jrr Jdine ell j#1H WW Than klrr Quilwf eHllrnerors m d',nllrwbin AN eMxk this kfa InuW Jmaehwl nn oaeilivyl.. col.uhnY a nfW alnJfril irlJieelin Ick. ttwl Jluwin IhY lac Y e mw f/nr rlla.smrrcnwaa toil Ikfa Wyrkfml•reTp,plllcy Illlbrrnanua /firm un earplayer thud it gravid/ng Ivorhrra'rurnpenmllon hLtornnee�or my otnp/upors. Br/ary/r the pu/4y and ab sld0 iu�dnnutGrn / Insuronc• '1 �2r�7r.I p r vne: CA Policy 4 or Sclr•ins. Lie.M; /OR 'L G / 6 7 7 O EApiratlon Date: �J• .� Z a,l JobSitlWresrCity,Slate/zip;: Sri L�/�J P-1k a c Attack rpy of 1110 workers'compensation pulley declaration page(showing rho policy nunibur and esplratlon date). 1'Jllure to..ecus coverage as required under Section 2251%ul'\IGL c. 152 can lead to the imposition ofcriminaI penalties of a line till 10.1'1.910.00,Intyur uue•year imprivlmmcnt, J' well as civil pcnalucs in the Penn of a STOP WORK ORDER and s fine 111% of up fit i250.00 n dry.Iguival the violator. He advi.+ed that a copy of this.xalu,nunt may be IurwordcJ to the O11ce ofg.Iu�nb of doe DIA 1i r u,.uraree covcrJyv tefilie Jhun. 1 /dm hereby t vrr//•r fifiJer tho ppoi�nt�m/rd prrto/Ncw„ry that the in/arrnallon prvriJtd above ii Irmo and earreoa ! I)Jll U/jleidl rue do/y. /)d nor n•ri[o in Noir arra, to be rernplefod by city dr tolem rr//lcidi (ity or fawn: Persalt/Lleen�e Y 1 Iwuing.tuthurity (circlonncl; - ' iI. llivJ of IlruNh 2. Ilwldin•g I)cpartmlcul L (.it)r'folvs Clerk J. L•'lectrical 11'sli or 5• Plumbing lntpeclor i b. Ihhcr l'�mlJct Panum:. I r I Information and Instructions I, on in the service of another un.ler any cundmct of hie. all canployers to provide workers' compensation to(their employees. \1.Isi.IGhUXCUa lJCoefal Laws ehaple[ I)2 rer(UIreY I'unuaad to dux,atutd,an rtno/erre is Jetined as.....every pevi ,,Press or unviicd, oral or %written." \n !,npluj,er Is dctined as..an individual.Purtneahip.associanoe,corporadun or other legal entity,or any two r the more t the t:,resomg engage) m a loins enterpnse,and including the legal represcny employing a deemployees.sed IHowever the i s«)ver a olli ee gage individual,in;aintperm r1s*-a association or other legal enosy,employing owner r r dwelling{house having not more than three apartments and who resides therein.or the occupant of the Jwclling house of another who employ" y"Persons enh n a sh 11 do notnbecause of such employment be Jcemtenance,4;vnsLr eJ rution of repair work on che dwelling empl ger or on the grounds or building appurtenant �IGL chapter 152, 025C(6) also states thal"every state or local licensing agency shall withhold the issuance or rrnewsl of a license ur permlt to uperate•business or to coestruct buildings In the homreunrage re for any llace with the Insurance Cava applicant wife hos not prnduerd acceptable p °brtesv­Neither the once of unonw�Ith not any Ofits Political subdivisions•shall 1JJitWnully, SIGL chapter I52, 4')5C(7) corer into any contract for the Performance ul'public work until acceptable evident;*ufcuntpliarice with the u+surnce e ter into ones of this ct for t have been presented to the contracting{authority." Applicants checking the boxes applyto our situation and.if Please fill out the workers' compensation atllJavit sits)completely.and hone nuttter(s)along with their certif)cuta(s)of necessary,supply sub-contractors)narne(y,rddress(os)red p with no em to res other than the insurance. Limited Liability Companies(LLCworka[s Limited eompetuwtioe iinuronce,(LLP) an)LLC or LLP does have member or partners, are not required ro carry employees.u Policy is required. Be advised that this atHdavit maca coverage. y be submitted to the d ditto the offIdAmen[of Industria Also be he rc�un eJ�u the confirmation iry or town that the apple tion for the permit aarolicense is being requested, not the p,Partmcnt Of Industrial j to the citts- Shull you have any quest' regarding the law or if you are required to obtain u workers' In ustriaution policy,please call the Deportment at the number listed below. Self-insured companies should enter their pe self-insurance license number on the ro nate line. City or'rown Omelets imcd Plea.¢affidavit i furyou ta ddill nutvit scomplete And prin the avant the OIFee legibly. Invest art onDepartment has to contact you regarding the tapphe licant. 1'I:ase be sure to till in the permiUliecnse nw`Cboioh which in anygivenedall eat,reed only reference submit oner. laf affidavit indicatingaddition, an current y y Y dctt must submit multiple pennio'Iiceltse app ' ' roviJeJ to the Policy intbrmution(if necessary)and under"Job Site Address'the applicant should write";til lucutiuns in (hey or town) A copy or the ugTlJuvit that has been officially stamper)or marked by the city or town Inay br'p ture y��r'c\there a proof ulne utwnerlid or citizen isdavit ls on fild for obtaining a license orrpermit no-mits or t related to any bustinessavit lor comust en+erc I venture a dug license a Permit ro burn leaves cte.)said Person is NOT required to complete this atfidavit. 1 I1C 0111c,: 1 tice to lilvcstlgations would I1"to think y'�lu Irl aJVIInCe lar your cooperation and%hUuld you hacC:rny rgYg11011s. please do not l+esimrc to give us a call. rhe Milartmcnt's address, telephone and ran numbdr. The Commonwealth of Massachusetts Department of Industrial Accidents OQlee of lavadgadons 600 Washington Street Boston, MA 02111 'Pel. q 617-727.4900 ext 406 or 1.877-MASSAFE Fax 0 617-727-7749 wvnv.may.gov/tie CITY OF S.U.E.�I, L L-usixCHCSE-FrS BuLLDLNG DEP.♦RT%L&NT ' 120 WASHLNGTON STREET, 3 'FLOOR ` TEL (978) 743-9595 FNt(978) 740.9846 KI\BER EY DRISCOLL MAYOR THOms ST.Pmaaa DIRECTOR OF nst tc PROPER TY/Bt:II.DLNG COMMISSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section I 11.5 Debris, and the provisions of MGL a 40, S 54; Building Permit p is issued with the condition that the dcbris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defincd by MGL c 111, S 150A. The debris will be transportcd by: � Q6Z3 (name of hauler) The debris will be disposed of in A U ACL S (name of facility) o A�-e , (address of facility) signature of permit applicant — date d.bnatlfd•w